Osama Rifaie

Percutaneous mitral valvotomy versus closed surgical commissurotomy. Up to 15 years of follow-up of a prospective randomized study

BACKGROUND Immediate and intermediate term results of percutaneous mitral valvotomy (PMV) are comparable to closed surgical commissurotomy (CSC). We aimed at exploring this relation in the long term. METHODS Previously, we randomized 40 consecutive patients with moderate to severe mitral stenosis [defined as mitral valve area (MVA) less than 1.5 cm²] to undergo either PMV (PMV group = 20 patients) or CSC (CSC group = 20 patients). For all patients, full echocardiographic assessment was performed before the procedure/operation. Patients assigned to PMV underwent the double balloon technique. Echocardiographic assessment was done following both procedures before discharge and repeated 1 and 6 months later. Echocardiographic follow-up was performed, thereafter, on a yearly basis for up to 15 years, with a mean follow-up period of 99 ± 12 months. RESULTS Immediate echocardiographic results showed no statistically significant difference between the 2 groups regarding the final MVA or mean diastolic gradient across the mitral valve. Two patients dropped out from the CSC group and one from the PMV group. MVA was 1.8 ± 0.3 cm² versus 1.8 ± 0.4 cm² (p > 0.05) and mean diastolic pressure gradient across the mitral valve was 7 ± 4 mmHg versus 6.6 ± 4 mmHg (p > 0.05) in the PMV and CSC groups, respectively. Mitral restenosis occurred in 5 (26.3%) patients in the PMV group versus 5 (27.8%) patients in the CSC group (p > 0.05). Kaplan-Meier curves for restenosis-free survival showed no difference between the 2 groups. CONCLUSION PMV achieves comparable results to CSC both in the short and long term.

Can a Novel Echocardiographic Score Better Predict Outcome after Percutaneous Balloon Mitral Valvuloplasty

Objective: The assessment of patients with mitral stenosis before percutaneous balloon mitral valvuloplasty (PBMV) is crucial to predict outcome after the procedure. We tried to explore the prognostic power of a novel echocardiographic score to predict immediate postprocedural outcome in comparison to the standard score. Methods: We enrolled 50 consecutive patients with moderate to severe mitral stenosis admitted to undergo PBMV. For all patients, we assessed both the standard Massachusetts General Hospital (MGH) score and a novel score based on calcification (especially commissural) and subvalvular involvement. Patients underwent PBMV with the double balloon technique. Thereafter, patients were classified into two groups: group 1 (poor outcome) defined as no procedural success and/or increase of MR by more than 1 grade and group 2 (optimal outcome) defined as procedural success with increase of MR by 1 grade or less. Results: The total MGH score did not differ significantly between the two groups. However, among the individual parameters of the score, both calcification and subvalvular affection were significantly higher in group 1 versus group 2 (2.8 ± 0.4 versus 1.7 ± 0.8, and 2.4 ± 0.5 versus 1.6 ± 0.4, respectively, P < 0.01 for both). The total novel score and its two individual parameters (calcification and subvalvular involvement) were all significantly higher in group 1 versus group 2 (6 ± 1.5 versus 2.9 ± 1.9, 4.9 ± 1.2 versus 2.4 ± 1.5, 1.5 ± 1.6 versus 0.5 ± 0.9, respectively, P < 0.01 for all). Multivariate analysis demonstrated the novel score to be the only independent predictor of poor outcome. Conclusion: The novel score is more reliable and correlates with outcome better than the standard score.

Immediate and long-term outcome of multiple percutaneous interventions in patients with rheumatic valvular stenosis

Aims: We sought to explore the immediate and long-term outcome of combined percutaneous valvuloplasty of the mitral and/or aortic and/or tricuspid valves in a series of patients with rheumatic valvular stenosis. Methods and results: A total of 11 patients (three underwent percutaneous mitral valvuloplasty [PMV], percutaneous aortic valvuloplasty [PAV] and percutaneous tricuspid valvuloplasty [PTV], six underwent PMV and PAV, and two underwent PMV and PTV) were enrolled. PMV was performed by the standard double balloon technique. PAV was always performed after PMV, employing the retrograde approach in eight patients and the antegrade approach in one patient. PTV was performed by the double balloon technique. Echocardiographic assessment was performed before and after the procedures. Follow-up was performed in all patients for a period that ranged from 12 and up to 60 months. PMV was successful in 10 out of 11 cases (91%); PAV was successful in all nine procedures (100%), while PTV was successful in four out of five cases (80%). At long-term follow-up, one case of restenosis occurred following PMV (9%), two following PTV (40%), and no restenosis occurred following PAV. Conclusions: Percutaneous balloon dilatation of rheumatic valvular stenosis is feasible with fairly adequate immediate and long-term outcome.

Alternate-day versus daily atorvastatin in coronary artery disease: a randomized study.

OBJECTIVE We sought to compare the effect of alternate-day versus daily atorvastatin 10 mg, on serum low-density lipoprotein cholesterol (LDL-C) and high-sensitivity C-reactive protein (hs-CRP) in patients with coronary artery disease (CAD) and controlled serum LDL-C by daily atorvastatin. METHODS The study was prospective, randomized, single-blinded, two-armed. Randomization was performed by a computer-generated randomization list. We randomized 60 patients with CAD and controlled serum LDL-C to receive either atorvastatin in the standard-dose of 10 mg daily (Group A=30 patients), or the same medication every other day (Group B=30 patients). Primary efficacy criterion included changes in serum LDL-C and hs-CRP from the initial to the 6-week follow-up values. RESULTS The mean age was 54.5±7.7 years, (70% males). LDL-C was significantly lower in Group A as compared with group B at 6-week follow-up (88±21 versus 105±26 mg/dl, respectively, p=0.008). Similarly, the mean percent increase of LDL-C from baseline to final assessment was significantly lower in Group A as compared with Group B (1.5±0.2 versus 32.8±6.2%, respectively, p<0.0001). However, the mean percent change of hs-CRP value was statistically similar between the two groups (p=0.108). Patients reported no side effects attributable to the medication. CONCLUSION The current pilot study demonstrated that in patients with CAD who have achieved target LDL-C level, maintenance on alternate-day atorvastatin 10 mg was inferior to daily atorvastatin in keeping LDL-C below the target level; however, it produced a similar effect on hs-CRP.

Immediate and Long‐Term Outcome of Redo Percutaneous Mitral Valvuloplasty: Comparison with Initial Procedure in Patients with Rheumatic Mitral Restenosis

AIMS We explored the immediate and long-term outcome of redo percutaneous mitral valvuloplasty (PMV) in a series of patients with mitral restenosis in comparison with initial PMV in the same series. METHODS We enrolled 40 consecutive patients presenting with mitral restenosis after successful initial PMV. Redo PMV was performed by the antegrade transseptal approach using either the Inoue technique or the multitrack technique. Reassessment by transthoracic echocardiography was repeated 48 hours later, and annually thereafter. Procedural success was defined as 50% or more increase of mitral valve area (MVA) with a final MVA >or=1.5 cm(2), without major complications. Restenosis was defined as loss of >50% of the initial gain of MVA by the preceding PMV with a final MVA <1.5 cm(2). RESULTS Procedural success was achieved in 37 (92.5%) patients. Both the initial and redo procedures were similar concerning the final MVA and mean transmitral pressure gradient (P > 0.05 for all). The gain of MVA was higher in the initial as compared to the redo procedure (P < 0.001). The initial mitral valve score correlated negatively with the final MVA in both the initial and redo procedures, and was the only independent predictor of the time to redo procedure, by multivariate regression analysis. At long-term follow-up (61 +/- 2.8 months), the mean MVA was 1.6 +/- 0.3 cm(2). Three patients--out of 12 available for follow-up--developed restenosis. CONCLUSION Redo PMV for mitral restenosis is feasible, safe, and achieves immediate and long-term outcome comparable to initial PMV.

Right atrial wall hematoma following percutaneous mitral valvuloplasty

A 50-year-old male underwent successful percutaneous mitral valvuloplasty for restenosis after surgical commissurotomy. Trans-septal puncture was difficult. Following the procedure, the patient developed chest pain and signs of systemic venous congestion, yet no hemodynamic collapse. Echocardiographic evaluation revealed a cystic mass compressing the right atrium, not communicating with the atrial cavity, mostly an intramural hematoma. The case was managed conservatively, and serial echocardiographic follow-up showed gradual reduction in size until ultimate disappearance of the mass 1 month later. In conclusion, right atrial intramural hematoma is a possible complication of mitral valvuloplasty, readily detected by echocardiography, and amenable for conservative management.

Artificial Intelligence-Based Assessment of Left Ventricular Filling Pressures From 2-Dimensional Cardiac Ultrasound Images

The estimation of left ventricular (LV) filling pressure from the ratio of transmitral and annular velocities (E/e′) is used commonly for identifying diastolic dysfunction in patients who complain of exertional dyspnea [(1)][1]. We have recently illustrated that LV and left atrial speckle tracking

Radius of proximal isovelocity surface area in the assessment of rheumatic mitral stenosis: Connecting flow to anatomy and hemodynamics

Background Echocardiographic assessment of left atrial pressure (LAP) in mitral stenosis (MS) is controversial. We sought to examine the role of the radius of the proximal isovelocity surface area (PISA-r) in the assessment of the hemodynamic status of MS after fixing the aliasing velocity (Val). Methods and results We studied 42 candidates of balloon mitral valvuloplasty (BMV), for whom pre-BMV echocardiography was done and LAP invasively measured before dilatation. PISA-r was calculated after fixing aliasing velocity to 33 cm/s. In addition, the ratio IVRT/Te’–E was also measured, where IVRT was isovolumic relaxation time, and Te’–E was the time difference between the onset of mitral flow E-wave and mitral annular early diastolic velocity. IVRT/Te’–E and PISA-r showed a strong correlation with LAP (r = −0.715 and −0.637, all p < 0.001) and with right-sided pressures. In addition, PISA-r correlated with mitral valve area by planimetry method (MVA) and with left ventricular outflow tract stroke volume (r = 0.66 and 0.71, all p < 0.001). Receiver operator characteristic curve (ROC-curve) showed that PISA-r was not inferior to IVRT/Te’–E in differentiating LAP ⩾25 from <25 mmHg. Conclusion Provided that Val is set to a constant of 33 cm/s, PISA-r can assess the hemodynamic status of MS, and seems a simple alternative to the tedious IVRT/Te’–E for estimation of LAP.

THE ABILITY OF THE RADIUS OF PROXIMAL ISOVELOCITY SURFACE AREA TO ASSESS THE ANATOMIC AND HEMODYNAMIC SEVERITY OF MITRAL STENOSIS AFTER FIXING ALIASING VELOCITY

Proximal isovelocity surface area (PISA) has emerged as an accurate method for assessment of mitral valve area (MVA) in patients with mitral stenosis (MS). Test the hypothesis that PISA radius (PISA-r) can be used to assess MS if aliasing velocity (Val) is set to a constant. 70 consecutive

Near-fatal cardiac arrest due to cardiac tamponade during percutaneous mitral valvuloplasty

The incidence of hemopericardium following percutaneous mitral valvuloplasty is reported at 1–3%, being related to either trans-septal puncture, or left ventricular perforation with guide wires or balloons. We report a case of percutaneous mitral valvuloplasty for a middle-aged man with moderately severe rheumatic mitral stenosis. The procedure was performed through a right femoral vein approach, employing the multitrack technique, utilizing 2 balloons (20 and 18 mm). Inadvertently, the procedure was complicated by cardiac tamponade. Despite immediate diagnosis and prompt pericardiocentesis, hemodynamic stability was not maintained. Echocardiography revealed a mass in the posterior pericardial sac. The patient was arrested in asystole, and rigorously resuscitated during transfer to the operating room. Exploration revealed a tear in the left ventricular apex that was adequately sutured. In a few days, the patient gradually regained adequate consciousness, and was ultimately discharged. Post-procedural echocardiography revealed a mitral valve area of 1.9 cm2, with no mitral regurgitation.